Tag Archives: swine flu

How well do you think the federal government performed in handling the 2009-2010 pandemic H1N1 influenza outbreak? Here’s the view of the physician who oversaw the effort at the U.S. Department of Health and Human Services (HHS), Dr. Nicole Lurie: “Looking back, I just feel very proud of what we accomplished as a nation.”

HHS Photo of Nicole Lurie, MD by Chris Smith

Dr. Lurie spoke last week at a meeting sponsored by the Infectious Diseases Society of America, in which participants reviewed the response to the pandemic flu in terms of what worked and what didn’t, and brainstormed to devise a list of priorities for future approaches to both pandemic and seasonal influenza.

The IDSA will incorporate those discussions into a revision of its January 2007 document, “Pandemic and Seasonal Influenza Principles for U.S. Action.” Back then, public health officials were concerned about the H5N1 “bird flu” virus as a possible pandemic strain.

“We were planning for a ‘different’ pandemic. But planning let us ‘pivot.’ Prior investments paid off in terms of vaccine manufacturing capacity and a strengthened public health system,” noted Dr. Lurie, who became the HHS Assistant Secretary for Preparedness and Response in June 2009, 2 months after the first case of pandemic H1N1 influenza was detected. Prior to that, she directed public health and preparedness work at the RAND Corporation.

Among the government’s major accomplishments, she noted, were the initial identification and sequencing of the virus, provision of test kits for states and for other countries, and delivery of the vaccine “in record time” to more than 70,000 sites, over 116,000 providers, and 10,000 retail pharmacy stores. As a result of the combined efforts of several different agencies within HHS, more than 80 million people were vaccinated.

But, of course, there were gaps and opportunities for improvement. Response time needs to be faster for making vaccine and implementing other medical countermeasures, and for obtaining funding. Indeed, there was a time lag of about 6 months for Congressional budget appropriations to reach the federal, then state and local levels to the actual shot in a person’s arm. “We have to be more nimble about moving money.”

Photo by G C Lee via Flickr Creative Commons

Communication with the public could also be improved. “Addressing public concerns is key. The health care system handled this one well, but would be challenged in a more severe pandemic. You can never communicate enough,” she noted.

HHS is addressing these and other concerns, including building stronger day-to-day systems within those already in place, incorporating surveillance and scientific endeavors along with clinical care. The ultimate goal, as informed by the 2009 H1N1 influenza pandemic: “Ensure that we are prepared for something we have never seen.”

The pandemic caused by the 2009 H1N1 influenza virus is now post-pandemic, according to a statement issued today by WHO Director-General Dr. Margaret Chan.

We should consider ourselves lucky that the 2009 H1N1 virus remained relatively mild, despite its hostile takeover of other circulating flu viruses last fall. Now, according to data from the WHO, many countries where seasonal flu is occuring are reporting a mix of viruses. So, it sounds like the 2009 H1N1 is settling down to play happily in the mix with other circulating flu viruses, learning how to take turns with the likes of H1N3 and influenza B, which join 2009 H1N1 in the 2010-2011 seasonal flu vaccine. But hold on to your hand sanitizer—“Pandemics, like the viruses that cause them, are unpredictable,” Dr. Chan said in her statement. And she’s right: Think back to every horror movie you have ever seen, or any book where it seems like the villain must be dead.

courtesy of flickr user sdecoret (creative commons)

“No one could have survived that fall/ explosion /fire/gunshot wound/ decapitation/banishment to a parallel universe.”

Not until it’s time for the sequel.

The 2009 H1N1 pandemic was, in many ways, a trial run for how the government and the medical community can work together to provide information—and health care—to the public in an emergency. There is room for improvement, especially as social media evolves, but the regular media updates and availability of information online was at least a starting point for communicating this type of news effectively. And even though there has been some controversy over whether governments ordered too much of the H1N1 vaccine, one could argue that it is better to have too much than not enough. Imagine the panic if the H1N1 virus had been deadlier, and there was a vaccine shortage.That’s another potential positive side effect of the 2009 H1N1 pandemic—a revisiting of the vaccine-making process. Maybe we can look forward to quicker, more efficient vaccine production. Maybe not right away, but perhaps in time for H1N1 II: The Swine Flu Strikes Back. Coming Soon to a Germy Person Near You.

“Continued vigilance is extremely important,” Dr. Chan said in her statement. To that end, the WHO offers recommendations for the post-pandemic period on its website, and the CDC continues to provide the latest flu information.

Even though the Centers for Disease Control and Prevention identified pregnant women as one of the five initial target groups to receive the 2009 monovalent H1N1 influenza vaccine, many pregnant women report not knowing about the importance of vaccination.

The finding comes from a cross-sectional study of 813 postpartum women at the University of Colorado Hospital conducted between November 2009 and May 2010. Barbra M. Fisher, a maternal-fetal medicine fellow at the University of Colorado, Denver, reported that 64% of women received the seasonal influenza vaccine during the study period and 54% received the novel H1N1 influenza vaccine.

Women who chose not to receive either vaccine cited the following reasons for opting out: not knowledgeable about the importance of vaccination (25%), concern for effects on fetal health (18%), concern for effects on maternal health (9%) and not knowing where to obtain vaccination (9%). In addition, 6% said that the vaccine was not available to them.

The findings, Dr. Fisher said, suggest that future vaccination campaigns “should focus on education of vaccine safety, enhance provider-patient education and communication –– targeting specific portions of the population –– and early availability of appropriate vaccines.”

The Centers for Disease Control and Prevention today released nationwide data on H1N1 vaccine uptake rates from October through the end of January, and the state-by-state variation in rates, especially in children aged 6 months-17 years, is nothing short of astonishing. And as of now, the CDC really has no good explanation for what’s been going on.

MMWR April 2, 2010;59:363-7

State H1N1 vaccination rates in this age group varied from a remarkably high 85% in Rhode Island to a low rate of 21% in Georgia. In contrast, the state-by-state variation among adults aged 18 or older was far tighter, ranging from a high of 39%, als0 in Rhode Island, to a low of 13% in Mississippi. In other words, the gap between the highest and lowest state rates among children–64%–was about 2.5-fold higher than the range in adults–26%.

The state by state rates for children (see map, upper panel) also seems to defy any logical pattern, aside from the cluster of high-rate states in New England. There is a high-rate state, Arkansas (50% vaccination rate) sitting next to several low-rate states including Louisiana (24%) and Texas (25%). Georgia’s low-ball rate of 21% juxtaposes with the relatively high rate of 45% in nearby North Carolina. Even in New England, there is a relative outlier in New Hampshire, where its 46% rate pales next to neighboring Vermont (72%), Massachusetts (60%), and Maine (60%).

The CDC offered some possible explanations for the states with high rates: a focus on childhood vaccination, use of an existing childhood vaccination infrastructure, running school-based vaccine clinics, and better recognition of the value of vaccination by parents and providers. Among these, the school-based clinics got the biggest play today, but even that doesn’t seem to tell the whole story. As the CDC’s Dr. Anne Schuchat noted, most states had at least some school-based clinics.

As the CDC noted in its report, the good news for vaccine advocates is that having locations with such high rates bodes well for eventually finding out what happened and building on it in the future. And trying to extend it to adults. But the CDC has a lot of data mining in its future to figure out what was behind this incredible regional variation.

The H1N1 vaccination numbers are in for January, and the federal effort to promote this vaccine has come up way short.

The upshot, last Friday, was a plea from the Dr. Anne Schuchat during a CDC press conference: “Many people believe the outbreak is over, and I think it’s too soon for us to have that type of complacency…We are not at all out of the woods because the [H1N1] virus continues to circulate.”

courtesy Public Health Image Library, CDC

Dr. Schuchat, a leader of the CDC’s H1N1 vaccination campaign, faces a tough sell to the American public, and the numbers she reported Friday tell the story: According to a U.S. survey by the CDC, about 70 million Americans (23% of the U.S. population) received at least one H1N1 vaccine dose through January 30, an increase of only 9 million since the last survey that covered the period through January 2. In contrast, 61 million received the vaccine from its U.S. introduction at the start of last October through Jan 2. In other words, an average of 20 million people a month got the vaccine during the first 3 months, when distribution was mostly limited to high-risk people, compared with 9 million during January, when the vaccine was available to anyone who asked for it.

These statistics were largely confirmed by results from a second, independent survey conducted by Harvard researchers, who also reported on Friday that 21% of Americans had received the vaccine as of late January. The Harvard poll also found that 44% of Americans said that the H1N1 outbreak was over.

The H1N1 vaccine uptake numbers look especially bleak given the heavy publicity the campaign received when the vaccine came out last fall, and again early in January during the National Influenza Vaccination Week. And in a striking contrast, last fall 32% of Americans received the seasonal flu vaccine for 2009-2010, according to a RAND corporation report, an incredible irony because the flu strains covered by that vaccine have largely been out of circulation this flu season. Near the end of the 2008-2009 flu season, 38% of Americans had received that season’s vaccine, RAND also reported.

What’s the problem with H1N1? “Our results show there was broad awareness of the public health messages on H1N1; approximately 3/4ths of the public reported seeing ads regarding the importance of getting the H1N1 vaccine since December, but many people did not respond to the message,” said a researcher from the Harvard survey.

The CDC and its parent federal department need to do a lot of self-examination to figure out how they failed so dramatically.

I’m a healthy 39-year-old with no chronic health conditions that put me into one of the H1N1 vaccine priority groups. Still, when I found out yesterday at a routine visit that my ob.gyn was offering the vaccine to all patients, I couldn’t roll up my sleeve fast enough. I felt a little guilty given shortage problems with the H1N1 vaccine in recent weeks…but not guilty enough to forego the shot. I rationalized getting the vaccine by thinking that the public health is better off with everyone who wants the H1N1 vaccine getting it. Why turn away those who want it?

Last week, the new vaccine for pandemic influenza H1N1 reached the American public, with some 4 million doses available nationwide and promises that an additional 20 million doses will reach U.S. vaccine dispensers weekly through the rest of this year.

courtesy Sanofi Pasteur

Along with the vaccine came a high-intensity publicity campaign by government officals urging the American public to get vaccinated. On Tuesday and Wednesday, Kathleen Sebelius, Health and Human Services secretary, appeared on a series of morning news shows promoting the vaccine. Also last Tuesday, Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, spoke in a press conference where his main message was that the new vaccine was safe and effective. On Friday, the CDC’s Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases, made similar pitches in a second news conference.

A cynic might say the CDC, HHS, and possibly the entire Obama administration has a major stake in making sure the H1N1 vaccine gets widely used and succeeds. After all, HHS has spent more than $6 billion in this effort and has placed a whole lot of reputation, credibility, and careers on the line. If the vaccine becomes mired by an adverse effect, poor performance, or an unconvinced public that refuses to get vaccinated, it’s easy to expect that heads would roll, embarrasment would run rampant, and the vaccine cause would be set back a few decades.

The 2009 H1N1 vaccine program is a public health juggernaut that’s a lot more than business as usual for the CDC and HHS. As Dr. Schuchat noted on Friday, the CDC usually handles about 10% of the annual, seasonal flu vaccine program, with 90% in other hands. In contrast, the H1N1 vaccine is 100% Uncle Sam, with the government fully responsible for footing the bill and hence also in line to take the credit or the blame depending on how it sorts out.

But there’s more to the last week of salesmanship than bureaucratic responsibility and fear of failure. While I have no prior, personal experience covering Secretary Sebelius or Dr. Frieden, I have seen Dr. Schuchat talk on various infectious disease and public health issues over the years, and, based on that history I’m convinced she now sincerely believes this vaccine is what’s best for the health of the nation. It’s moments like these, when a possibly calamitous infection is knocking on the door, that the public-health lifers at places like the CDC train for and live for.

Last week also brought the good news that the uptake bar might not be set very high for the H1N1 vaccine to succeed. A modeling analysis released by Annals of Internal Medicine showed that vaccinating 40% of the population in a hypothetical city of 8 million people in October or November stood to prevent morbidity in tens of thousands and save hundreds of millions of dollars. Even vaccinating just 15% of the population in October could avert more than 700,000 infections and more than 700 deaths and save more than $160 million in one large city.